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Common HA/less serious causes

Cervic­ogenic HA

Clinical Findings
Reduced Neck ROM
Reproduced by moving the neck/p­ressure over C2 NR
Ipsila­teral Should­er/Arm Pain
Unilat­eral, Doesn't change sides
C1-C3 NR affected
Can present with Nausea, Vomiting, photo/­pho­nop­hobia
TrP in Upper Traps, Lev Scap, Scales + Subocc­ipital Extensors
Weak Deep Neck Flexors


A. Pain referred from a source in the neck & perceived in >1 regions of the head/face + C+D
B. Clinic­al,­lab­/im­aging evident of a disord­er/­llesion within the cx or soft tissues of the neck known to be,or generally accepted as, a valid cause of HA (no cx spondy­losis)
C. Evidence of HA caused by neck dysfun­ction - criteria at least one of the following:
1. clinical signs that point to a pain in the neck
2. abolition of HA - diagnostic blockade of cx structure
D. Pain resolves within 3 months of treatment


Physical Therapy:
Cx Spine Mobili­sat­ion­/Ma­nip­ulation
Upper Quarte­t/DNF streng­thening
Tx Spine Manipu­lations + Exercise
Postural Training
Muscle relaxants
Steroid Inject­ion­s/Nerve blocks

Tension Type Headaches

Bilateral, Pressi­ng/­tig­htening
Mild-M­oderate Intensity
Can present with migraine symptoms (nausea, vomiting, photo/­pho­nop­hobia
Usually lasts minutes to days


Cx Exercises
Postural Exercises
Cranio-cx technique
1000mg parace­tamol + 130mg caffeine

Hypnic HA

Headache that wakes patient up at night
Can be unilat­era­l/b­ila­teral
Begins abruptly
Can have autonomic features
Dull-m­oderate severity
Responds well to lithium + caffeine


Exclude 2ndary HA - drug withdr­awal, sleep apnoea, brain tumours, TA
Exclude primary HA - migraines, cluster HA, chronic paroxysmal hemicrania
Refer to GP - specialist
Lithiu­m/c­affeine most effective

Red Flags

- HA that is progre­ssively worse over time
- Sudden onset
- Severe HA
- New/un­fam­iliar HA
- HA with head trauma
- Unexpl­ained weight loss
- Impaired consci­ousness
- Fever
- Signif­icant neck stiffness
- Rash
- Nuchal rigidity
- Vertigo
- Diplopia
- Drop attacks
- Difficulty speaki­ng/­swa­llo­win­g/w­alking
- Nystagmus


- Systemic symptoms: Fever, weight loss, Cancer/HIV
- Neurol­ogical signs: confusion, impaired alertness, consci­ousness
- Onset: sudden­/abrupt onset - develops and peaks quickly
- Older: New HA in patients >50 years old (GCA, bleed, stroke)
- Previous HA hx: new HA - different in frequency, severity and clinical features


Unilat­eral, severe pulsat­ing­/po­unding HA
Radiates to perior­bit­al/­ret­roo­rbi­tal­/fr­ont­al/­tem­por­al/­ocular areas
Nausea, photo/­pho­nop­hobia, lack of appeti­te,­moo­d/l­ibido
Can be with aura/w­ithout
Scinti­llating scotoma (flash­y,z­igziggy lights - obstruct visual field)
Can present with hemiplegia and cold extrem­ities
Prodrome, aura, attack, postdrome
Lasts between 4 and 72 hours
Prodrome: Lethargy, yawning, food cravings, mood changes, excessive thirst, fluid retention, consti­pation, diarrhoea, hypers­ens­itivity to light, sound or odors
Aura: Develops slowly over 5-20 minutes (disti­ngu­ishes between TIA/st­roke) - lasts up to an hour - Commonly visual distur­bances (scint­ill­ating scotoma - a piece of absent vision with shimmering border), tunnel vision
Parest­hesia is 2nd most common - numbness in hands and then up to arm, face , lips, tongue
Motor symptoms can be present - heaviness in limbs/­speech and language distur­bances
Postdr­omal: Occur in hours following the attack - fatigue, irrita­bility, euphoria, myalgia, food insens­iti­vit­y/c­ravings
Vital signs may reveal - bradyc­ardia, tachyc­ardia, hypert­ension, hypote­nsion
Observ­ation can reveal Horner's syndrome (mild - ptosis and miosis) ipsila­teral to HA Presence of papill­edema = further invest­igation
Palpate temporal artery in >50 yo
Limited Cx ROM
Assess cardio­vas­cul­ar/­ceb­rov­ascular issues - migraine patients have an increased risk of cardio­vas­cular disease


- Migraine without aura
- Migraine with aura (autonomic nervous system - occurs immedi­ately prior to the headache
- Visual distur­bances, extremity parest­hesia, nausea, vomiting, hypers­ens­itivity to light/­sound
- IHS: Five episodic headaches, each lasting 4-72 hours + nausea­/vo­miting or photop­hob­ia/­pho­nop­hobia with >2 of the charar­act­eri­stics:
modera­te-­severe intensity
unilateral presence
pulsating quality
aggravated by physical activity (can be bilateral and non-pu­lsa­ting)


Drugs: Aspirin (900mg), ibupro­fen­(40­0-8­00mg), parace­tamol (1g) - SSRA and ergot alkaloids, beta-b­loc­kers, tricuclic antide­pre­ssants, divalproex sodium, valproic acid (be careful of overuse headaches)
Lifestyle Changes - identi­fying Triggers (Headache diary), if medica­tion, patient should see their GP, dietary advice, hydration
Massage of SCM, upper traps, splenius capitis, subocc­ipital, inters­capular and shoulder girdle muscles
Stress relief
Cold pack @ back of neck
SMT of Cx (be careful of risk of stroke)
Strengthen DNF and postural advice for upper crossed
Headache diary
Aerobic exercise - 40 minutes 3x a week
Magnesium, vitamin D, calcium, B6 supple­ments
Botox injections
Surgical care is discou­raged

Risk Factor­s/D­emo­gra­phics

- Mainly females more than males
- High economic cost - lost workdays
- Migraine without aura = peaks in boys aged 10 and girls aged 17
- Before puberty, migraine is more common in boys, after puberty its girls
- peaks@ 3rd decade, decreases after 4th decade, new onset migraine HA after 50 is rare
- Genetics
- Low cardio­vas­cular fitness
- Hypert­ension, hyperc­hol­est­ero­lemia, impaired insulin sensit­ivity, coronary artery disease, hx of stroke
- Medication overuse - acetam­ino­phen, naproxen, aspirin, opiates, barbit­urates, triptans
- Hypoca­lcemia and vita D defici­encyy
- Triggers - stress, smoking, strong odors, bright­/fl­ick­ering lights, fluore­scent light, excess­ive­/in­suf­ficient sleep, head trauma, weather changes, high humidity, motion sickness, cold stimulus, lack of activi­ty/­exe­rcise, dehydr­ation, hunger, hormonal changes, upper cx tensio­n/c­erv­ico­genic HA
- Medica­tions - oestrogen, oral contra­cep­tives, vasodi­lators, nitro-­gly­cerine, histam­ines, reserpine, hydral­azine, ranitidine
- Food triggers - alcohol, excessive caffeine, artificial sweete­ners, MSG, soy sauce, citrus fruits, papayas, avocados, red plums, overripe bananas, dried fruits, sour cream, butter­milk, nuts, peanut butter, sourdough bread, aged meats and cheeses, processed meats, anything fermented, picked, marinated


Not usually considered
If pathology suspected - MRI
If cerebral vascular pathology - aneurysm, vascul­itis, arterial dissection - MRA


- TTH (bilat­eral, non-pu­lsatile not aggravated by physical activity)
- TIA/stroke (more quickly and lasts longer)
- Cluster HA
- Acute Glaucoma
- Meningitis
- Neoplasm
- Cerebr­ova­scular bleed

Cluster HA (Rare) - TAC

Excruc­iating unilateral perior­bit­al/­tem­poral pain
Sharp, pulsating, pressure like pain - usually on the right side
ipsila­teral autonomic symptoms: Conjun­ctival injection & lacrim­ation, nasal conges­tio­n/r­hin­orhea, forehe­ad/­facial sweating, facial flushing, eyelid oedema, miosis­,ptosis
Restle­ssness & agitation
Can present with Auras,­pho­to/­pho­nop­hobia, nausea + vomiting
Pain in 1st trigeminal branch - always on same side of head
Physical activity relieves pain


Avoid Triggers
GP Referal
Triptans, steroids, oxygen inhalation

Occipital Neuralgia

Pierci­ng/­thr­obbing in upper neck, back of the head, behind ears
Scalp tender to touch


Pinching of the nerves (greater + lesser)
Tight muscles - microt­rauma
Too much extension for long periods
Tumour in neck


Nerve block
Treating underlying cause


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